National CERT data showed projected rises in improper payments for outpatient E&M services for 2013 with CPT codes 99205 and 99215 being in the top 15 codes identified for improper payment. Previous review of high level outpatient E&M services resulted in high error rates because services were frequently billed at a higher level than could be supported for medical necessity by the medical record.
Audit Results: The overall percentage of services recoded or denied for CPT 99205 was 78.66%. The overall percentage of services recoded or denied for CPT 99215 was 78.50%. The key reasons services were denied are as follows:
- Failure to respond to the request for documentation
- Documentation was missing a provider signature
- Insufficient or missing documentation
- The medical record did not support the coverage requirements forservices of nonphysician personnel furnished incident to physician’s services billing
- Documentation did not support a separately identifiable E&M service performed in addition to procedure billed for the same date of service (inappropriate use of modifier 25)
The key reasons services were recoded to a lower level E&M service are as follows:
- The medical record failed to support the medical necessity of the highest level of outpatient E&M service
- For new patient E&M service CPT 99205, all 3 key components (comprehensive history, comprehensive examination, and high complexity medical decision making) were not supported at the level billed
- The provider selected the level of E&M using time as the controlling factor, but the medical record failed to differentiate physician time devoted to face-to-face counseling with the beneficiary from the time dedicated to history and physical examination; or the record failed to provide sufficient detail about the coordination of care or counseling provided to justify the level of E&M billed
The majority of the services billed as CPT 99205 were recoded one or two levels, and the majority of the services for CPT 99215 were recoded one level. Based on the results of this widespread audit, prepayment review of CPT 99205 and CPT 99215 will resume for Part B claims in Illinois, Minnesota and Wisconsin beginning June 2014.
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General Comment says:
For new patient E&M services, all three key components (i.e., history, examination, and medical decision making) must meet or exceed the stated requirement of the level of service billed. A beneficiary who has not received any professional services from the physician or same specialty within the physician group practice within the previous three years is considered a new patient.The CPT Manual states physicians typically spend 60 minutes face-to-face with the patient for CPT 99205 and 45 minutes for CPT 99215, and the presenting problems are of moderate to high severity for both codes.
It is important to remember that medical necessity is the overarching criterion for services billed to Medicare. Medicaldecision making refers to the complexity (straightforward, low, moderate, and high) of establishing a diagnosis and management options. Three elements are used to determine the medical decision making level: number of diagnoses and/or number of management options considered, amount and/or complexity of data to be reviewed, and risk of complication and/or morbidity or mortality. The duration of a visit is not the controlling factor in determining the appropriate level of an E&M service unless more than 50 percent of the face- to-face physician time is spent providing counseling or coordination of care.
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